Adenomyosis is uterine lining inside the muscle of the uterus. It can cause very painful, heavy periods.
- How is it recognised? History and examination, then ultrasound. Pelvic MRI maps the uterus before any operation.
- Is surgery always needed? No. Medical treatment comes first.
- Is hysterectomy the only operation? No. A hysteroscopic endometrectomy can be discussed. Hysterectomy is the radical step.
- Where is this decided? In consultation.
Adenomyosis is a common gynaecological condition that has long been under-recognised. It affects between 20 and 35% of women of reproductive age, with a peak between 35 and 50. In practical terms, it is the infiltration of the uterine lining (the endometrium) into the muscle of the uterus (the myometrium). The result: periods that have become very painful, very heavy, and a uterus that gradually enlarges.
Adenomyosis is distinct from endometriosis, even though both conditions can coexist. In adenomyosis, endometrial tissue remains inside the uterus — it infiltrates the muscle. In endometriosis, the same tissue develops outside the uterus: on the ovaries, fallopian tubes, peritoneum, sometimes on the rectum or bladder. Management is not the same.
This article takes stock of the symptoms that should prompt review, the diagnostic strategy (transvaginal ultrasound, pelvic MRI, hormone workup), first-line medical treatments (hormonal IUD, continuous pill, GnRH agonists, Ryeqo), and surgical options when medical treatment is insufficient (hysteroscopic endometrectomy, hysterectomy). The logic is strictly stepwise: medical treatment always comes first. Note that at menopause, adenomyosis most often disappears.
Treatments no longer enough? Dr Zeitoun discusses surgery with you when medical treatments do not bring enough relief.
Understanding adenomyosis
Adenomyosis is the abnormal infiltration of endometrial tissue into the thickness of the uterine muscle. To understand the condition and the rationale behind treatments, it first helps to recall how a uterus is built.
Three layers in the uterine wall
The uterus is made of three layers. On the inside, the endometrium — the lining — thickens during the cycle and is shed each month at the time of periods. In the middle, the myometrium is the powerful muscle that contracts the uterus (periods, childbirth). On the outside, the serosa covers the organ.
In adenomyosis, endometrial glands pass into the muscle. These glands remain sensitive to the hormones of the cycle and bleed like normal endometrium — except that they bleed inside the muscle. This explains the pain, the inflammation, and the progressive enlargement of the uterus.
Deep infiltration of the muscle
Endometrial glands penetrate the myometrium and form ectopic foci. These foci respond to the hormonal cycle and bleed within the muscle — creating local inflammation, hypertrophy and pain.
Diffuse adenomyosis
The disease affects the entire myometrium. The uterus is globular, uniformly enlarged — sometimes doubled or tripled in size. This is the most common form.
Focal adenomyosis (adenomyoma)
The disease is concentrated in one area, forming a nodule called an adenomyoma. This form is rarer than diffuse adenomyosis.
👉 In practice, whether diffuse or focal, adenomyosis follows the same management logic.
3D anatomical representation: endometrial glands are seen infiltrating the thickness of the uterine muscle.
Asymptomatic, fibroids, endometriosis: what to know
Adenomyosis can be entirely asymptomatic and only be discovered incidentally, on an ultrasound or MRI performed for another reason. In such cases, no treatment is needed.
Adenomyosis is also often associated with other uterine conditions:
- Uterine fibroids — both diseases frequently coexist, and both can contribute to heavy bleeding.
- Endometriosis — about one in two patients with adenomyosis also has endometriosis. Conversely, many patients with endometriosis also have adenomyosis.
This frequent coexistence matters: it sometimes changes treatment strategy and preoperative workup.
Known risk factors
Several factors increase the risk of developing adenomyosis. None on its own is enough to confirm the diagnosis, but they help guide clinical suspicion.
- Age between 35 and 50 — peak prevalence in this age range.
- Multiparity — several previous deliveries.
- Previous uterine surgery — caesarean sections, curettage, hysteroscopy.
- Hyperoestrogenism — favouring hormonal background.
- Genetic predisposition — family history of adenomyosis or endometriosis.
- Smoking, overweight — documented modulating factors.
Recognising adenomyosis
Adenomyosis presents with a relatively stereotyped set of symptoms. Their intensity varies with the extent of the lesions, but also with individual sensitivity — some women suffer little despite extensive adenomyosis, and vice versa.
Chronic pelvic pain is one of the most commonly reported symptoms.
Very painful periods
Severe dysmenorrhoea is the most common symptom. The pain often starts before periods begin, persists after they end, and is resistant to usual painkillers (paracetamol, ibuprofen). Many patients describe pain that forces them to stop their activities.
Menorrhagia
Very heavy and prolonged periods (often > 7 days), sometimes with clots. The almost inevitable consequence: iron deficiency anaemia — fatigue, breathlessness, pallor. Protection needs to be changed every 1 to 2 hours in the first few days.
Metrorrhagia
Bleeding can also occur between periods, reflecting the instability of the ectopic endometrium within the muscle. This intermenstrual bleeding is sometimes mild (spotting), sometimes heavier.
Chronic pelvic pain
Outside periods, many patients describe a persistent pelvic heaviness, dull lower-abdominal pain, sometimes radiating to the lower back or thighs. This pain significantly impacts mobility and sleep.
Deep dyspareunia
Sexual intercourse can become painful at depth, particularly in certain positions. This dyspareunia is due to the sensitivity of the enlarged uterus and local inflammation. It often has an impact on the couple.
Compression symptoms
The increased uterine volume can compress neighbouring organs, causing bloating, bowel disturbance, urinary frequency, a sense of pelvic fullness. These symptoms are often wrongly labelled as "digestive".
Beyond physical symptoms
Adenomyosis has a major psychological impact that is too often underestimated. Chronic pain, unpredictable bleeding, fatigue from anaemia, impact on professional, social and intimate life frequently lead to anxiety, loss of confidence, mood disturbance.
This dimension must be taken into account in consultation: it is part of the disease, and it is a strong argument not to delay treatment when symptoms become disabling.
How is adenomyosis diagnosed?
The diagnosis of adenomyosis relies on a combination of findings: listening to the symptoms at consultation, clinical examination, then imaging. Pelvic MRI remains the reference test.
Consultation and examination
Detailed history-taking is fundamental: duration of periods, heaviness (number of protections per day), pain (intensity, timing, impact), effect on daily life, gynaecological and obstetric history, treatments already tried.
Clinical examination typically finds a uterus that is enlarged, firm, regular, tender. This uniform enlargement is suggestive — it differs from the localised deformation caused by fibroids.
Pelvic ultrasound
More accessible than MRI, pelvic ultrasound (usually transvaginal) gives initial pointers by showing the overall uterine appearance and muscle structure. It also detects associated fibroids when present.
A normal ultrasound does not exclude adenomyosis: when clinical suspicion is high, we add an MRI.
Pelvic MRI
Pelvic MRI is the reference investigation to confirm the diagnosis. It precisely visualises the uterine muscle thickness, the extent of disease, and helps to differentiate adenomyosis from other conditions (fibroids, associated endometriosis).
It is also the most useful investigation before a surgical decision, to map the uterus and choose the right technique.
Blood tests
Routinely performed to assess impact: haemoglobin, full blood count (anaemia from bleeding), ferritin and serum iron (iron deficiency), sometimes a hormonal workup (FSH, LH, oestradiol) in patients close to menopause.
Differential diagnosis: don't confuse with…
Several other conditions can produce similar symptoms. Imaging workup either rules them out or, more often, demonstrates coexistence (which is common).
- Uterine fibroids — localised deformations of the muscle, to be distinguished from adenomyomas.
- Endometriosis — disease outside the uterus (ovaries, peritoneum, tubes), may coexist.
- Endometrial polyps — diagnosed by office hysteroscopy.
- Endometrial hyperplasia — particularly in perimenopausal patients.
- Haematological causes — clotting disorders (von Willebrand disease).
- Malignant endometrial pathology — always to be ruled out after age 45.
The adenomyosis treatment pathway
A strictly stepwise strategy, from least invasive to most definitive. Most patients are relieved by step 2.
Each patient is unique. Treatment decisions are made together, taking into account your symptoms, age, pregnancy plans and response to previously tried treatments.
Endometrectomy or hysterectomy: Dr Zeitoun explains the indication and pathway for each option, depending on your situation.
Start with medical treatments
The treatment of adenomyosis follows a stepwise logic. Medical treatments come first, and they relieve most patients. Surgery is only considered as a second step, when medical treatments are insufficient, poorly tolerated or contraindicated.
Hormonal IUD (levonorgestrel)
The hormonal IUD (levonorgestrel-releasing IUD — several brands available in France: Mirena, Jaydess, Kyleena) releases progestogen directly into the uterus. It thins the endometrium, significantly reduces bleeding and relieves pain. Contraceptive effect included.
Inserted at the office, it acts for 5 to 8 years. Possible side effects: spotting in the first 3 months, breast tenderness, functional ovarian cysts.
Continuous pill
Continuous combined oral contraceptives (no pill-free week) suppress periods and the cycle-related symptoms. An alternative when the IUD is not appropriate.
Options: continuous classical pill, or progestogen-only options (desogestrel, dienogest). Dienogest has a specific indication in endometriosis and adenomyosis.
GnRH agonists
These injectable treatments create a reversible medical menopause. Symptoms (periods, pain) disappear quickly, but side effects (hot flushes, vaginal dryness) limit use to around 6 months.
Used short-term, for instance before surgery.
Ryeqo (relugolix combo)
Ryeqo is a recent oral treatment combining a GnRH antagonist with hormonal stabilisation (estradiol + progestogen). It controls painful and heavy periods without inducing a marked medical menopause. Good tolerance, once-daily intake.
An option when the IUD and the pill are insufficient or not suitable.
Comfort treatments
As adjuncts: painkillers for pain, treatment to reduce menstrual bleeding volume, and iron supplementation if anaemic.
👉 In most cases, these treatments are enough. Assessment is at 3 months then 6 months: if improvement is significant, we continue. If not, we discuss the next step — other medical options, or moving to surgery.
When medical treatment is not enough: surgery
The management of adenomyosis follows a strict stepwise logic: medical treatments come first. If they fail, conservative surgery is offered (hysteroscopic endometrectomy). If this step also fails, we move to the radical step: hysterectomy. To note: at menopause, adenomyosis most often disappears spontaneously — which may influence the decision in patients approaching that age.
Important: since endometrectomy destroys the endometrium, it is rarely used in patients with pregnancy plans. In that situation, strategy is discussed on a case-by-case basis.
Hysteroscopic endometrectomy
Operative hysteroscopy is the first surgical step. The procedure is done through the natural pathway (through the cervix), with no incision, as day surgery under brief general anaesthesia. The endometrium is destroyed or removed to eliminate bleeding and pain.
⚠️ This technique is rarely used in patients with pregnancy plans — endometrial destruction prevents embryo implantation.
Resection under camera
The endometrium is removed using an electric loop under visual control via hysteroscope. The procedure is precise, complete, and allows tissue to be sent for histology.
Heat destruction
A balloon or radiofrequency device is introduced into the uterine cavity and destroys the endometrium by heat. Quicker technique, without resection but without tissue sent for histology.
70 to 80% success
Periods are eliminated or significantly reduced in 70 to 80% of cases. Pain decreases alongside. The uterus is preserved.
⚠️ Absolute contraindication: pregnancy plans — destroyed endometrium prevents any embryo implantation.
Hysterectomy
When medical treatments and endometrectomy have failed, hysterectomy (removal of the uterus) is the radically definitive solution. It is the final step, offered to patients without pregnancy plans. To note: in patients close to menopause, watchful waiting can also be chosen — adenomyosis most often disappears at menopause.
Adenomyosis surgery is performed laparoscopically in the vast majority of cases — three to four 5 to 10 mm incisions.
Three small incisions
The reference route today. Three to four 5-10 mm incisions. Hospital stay 1 to 2 days. Return to normal activities in 2 to 3 weeks.
No abdominal incision
Possible if the uterine volume is not too large. The uterus is removed through the natural pathway. No visible scar. Recovery often fast.
Abdominal incision
Reserved for very large uteri or complex situations (re-do surgery, adhesions). Longer hospital stay and recovery.
Hysterectomy can be total (uterus + cervix) or subtotal (body of the uterus only, cervix preserved). This decision is always made together. The ovaries are almost always preserved in non-menopausal patients — no induced menopause.
Uterine artery embolisation
A technique performed by interventional radiology: via puncture of the femoral artery, embolising particles are injected into the uterine arteries, reducing blood supply to the adenomyosis foci.
Advantages: minimally invasive technique, uterus preserved, short hospital stay. Efficacy 70 to 80% on symptoms at 1 year, with a non-negligible recurrence rate at 3-5 years. Post-embolisation fertility is not guaranteed: best avoided in patients with pregnancy plans.
→ Indication agreed in consultation with an interventional radiologist.
Adenomyosis and fertility
Adenomyosis can affect fertility, but does not systematically prevent pregnancy. Many patients conceive naturally. Dr Zeitoun is a surgeon — fertility management itself is provided by a specialist (medical gynaecologist, assisted reproduction centre). Below are some pointers on the links between adenomyosis and pregnancy plans.
What the literature says
Adenomyosis can reduce embryo implantation rates and increase the risk of early miscarriage. The impact depends on disease extent — modest for limited forms, more marked for severe diffuse adenomyosis.
Care in a specialist centre
When adenomyosis complicates pregnancy plans, care is provided by a fertility specialist (medical gynaecologist, assisted reproduction centre). Dr Zeitoun is a surgeon — he does not manage fertility itself, but can refer to the right specialists.
No surgery if pregnancy plans
Endometrectomy destroys the endometrium — it is therefore contraindicated in patients with pregnancy plans. For these patients, management remains exclusively medical, in coordination with a fertility specialist if needed.
Tailored obstetric follow-up
Pregnancy on an adenomyosis uterus requires tailored obstetric follow-up (by the usual obstetrician): modestly increased risk of prematurity or complications, but most pregnancies proceed normally.
In summary
If you have adenomyosis and pregnancy plans, care is provided by a fertility specialist (medical gynaecologist, assisted reproduction centre). Dr Zeitoun, a surgeon, only intervenes when surgery becomes necessary — which is very rare before the end of the pregnancy project.
A word on the surgical pathway
Once surgery is decided, the pathway is well-framed and predictable. Pre-anaesthetic consultation is mandatory at least 48 hours before. A recent blood workup. For hysterectomies, haemoglobin is checked — iron supplementation may be needed if you are anaemic.
Hysteroscopy is day surgery in most cases: arrival in the morning, discharge in the afternoon. Laparoscopic hysterectomy involves a 1 to 2-day hospital stay. Laparotomy 3 to 5 days depending on context.
Recovery depends on the procedure: 1 week for hysteroscopy, 2 to 3 weeks for laparoscopy, 4 to 6 weeks for laparotomy. Sexual intercourse and baths are avoided for 4 to 6 weeks after hysterectomy. Driving resumes as soon as pain no longer interferes with emergency braking.
Frequently asked questions
The questions that come up most often at consultation. If yours is not here, feel free to ask at the appointment — or to Sophie, the site assistant, in the bottom right.
What is the difference between adenomyosis and endometriosis?
Adenomyosis and endometriosis are two different conditions, although they can coexist. In adenomyosis, endometrial tissue infiltrates the muscle of the uterus. In endometriosis, the same tissue develops outside the uterus: on the ovaries, fallopian tubes, peritoneum, sometimes the rectum or bladder. Dr Zeitoun manages adenomyosis surgically, but refers patients with deep endometriosis to specialised centres.
Can adenomyosis prevent pregnancy?
Adenomyosis can affect fertility but does not systematically prevent pregnancy. Many patients with adenomyosis conceive naturally. When adenomyosis is extensive and pregnancy is slow to materialise, targeted treatments can improve chances: medical preparation before assisted reproduction, personalised support. Discuss it at consultation: the strategy is tailored to your situation.
How is adenomyosis diagnosed?
Diagnosis is based on consultation (history and examination), pelvic ultrasound as the first line, and pelvic MRI which is the reference investigation to confirm the diagnosis and map the uterus before any surgical decision. Blood tests complete the workup to look for anaemia.
Does adenomyosis always require surgery?
No. First-line treatment is medical: hormonal IUD (Mirena, Jaydess, Kyleena), continuous pill, sometimes GnRH agonists or Ryeqo. These treatments significantly reduce or eliminate periods and relieve most patients. Surgery is considered only if medical treatment fails, is poorly tolerated or contraindicated — and always taking into account your life plans.
Is hysterectomy the only surgical option?
No. Surgery follows a stepwise logic: the first step is conservative — hysteroscopic endometrectomy (no incision, day surgery) eliminates periods in most cases while preserving the uterus. Hysterectomy is the radical step, offered only on failure. Note that at menopause, adenomyosis most often disappears spontaneously — which may influence the decision in patients close to that age.
Will adenomyosis disappear at menopause?
Yes, in the vast majority of cases. Adenomyosis is maintained by oestrogens. When hormonal production stops at menopause, adenomyosis foci atrophy and symptoms disappear or significantly subside. In patients close to menopause, watchful waiting under medical treatment is often preferable to surgery.
When should I seek urgent care for adenomyosis?
Seek care promptly if your periods become uncontrollable (changing protection every hour, bleeding that does not stop, faintness, extreme fatigue), or if you have signs of severe anaemia: breathlessness on effort, palpitations, dizziness, marked pallor. A scheduled consultation (but without delay) is justified by periods too painful to be controlled by usual painkillers, or significant impact on your professional, sporting or intimate life.
Planning a pregnancy? Dr Zeitoun takes it into account when choosing the surgery.